DeMatha Lacrosse 2017 Evening Summer Camp - July 18, 19 & 20th 6:00 - 8:00 pm
Please complete the following registration information. Upon completion of the form, click on the link provided to process your payment. If you have any questions, please contact demathalacrossecamps@gmail.com
Participant First Name
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Participant Last Name
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School
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Graduating Year
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Position
Date of Birth
(MM/DD/YYYY)
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Player's Home Phone
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Player's Email
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Street Address
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City
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State
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Zip Code
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Father's First & Last Name
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Father's Cell Phone
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Father's Email
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Mother's First & Last Name
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Mother's Cell Phone
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Mother's Email
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Emergency Contact Name
(In the event that a parent can not be reached)
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Emergency Contact Phone
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Insurance Company
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Policy #
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Parent/Guardian Consent & Liability Waiver
As parent and/or legal guardian, I remain legally responsible for any actions taken by the above named minor (“participant”).I agree on behalf of myself, my son named herein, or our heirs, successors and assigns to hold harmless and defend DeMatha Catholic High School, its officers, directors and agents and the DeMatha Lacrosse Camps, coaches, representatives associated with the camp, arising from or in connection with my son attending the camp or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate DeMatha Catholic High School, its officers, directors and agents and the DeMatha Lacrosse Camps, coaches, or representatives associated with the camp for reasonable attorney’s fees and expenses arising in connection therewith.
Required
Medical Information Statement
I hereby warrant that to the best of my knowledge, my son is in good health, and I assume all responsibility for the health of my son.
Required
Emergency Medical Treatment
In the event of an emergency, I hereby give permission to treat and transport my son to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above number, contact the emergency person listed on the application.
Required
Specific Medical Information
1. Please list below any medical conditions such as Asthma, allergies to medications, foods, insects, etc. as well as any physical limitations. 2. Has your child been exposed to contagious disease or conditions such as mumps, measles, chickenpox, etc? If so, please list dates and disease condition below. DeMatha will take reasonable care to see that the following information will be held in confidence.
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Special Medical Conditions/Needs of my participant
Please list below any special medical conditions or needs that we need to be aware of.
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Medications
My son is presently taking medication and will bring all such medication necessary, and all such medications will be well labeled. Please list names of medications and concise directions for taking such medications, including dosage below.
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Medication Permission
Please Check the appropriate option below
Required
Electronic Signature
Please type your name below - this will be accepted as your online signature.
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Date
(mm/dd/yyyy)
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